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Infant-caregiver interactions, seminal events in brain development and their possible relationship to later psychic vulnerability were explored in a recent continuing education seminar, "Understanding and Treating Trauma: Developmental and Neurobiological Approaches," at the University of California, Los Angeles.
Infant-caregiver interactions, seminal events in brain development and their possible relationship to later psychic vulnerability were explored in a recent continuing education seminar, "Understanding and Treating Trauma: Developmental and Neurobiological Approaches," at the University of California, Los Angeles. Presenters were Daniel Siegel, M.D., medical director of the infant and preschool service at UCLA and director of interdisciplinary studies, Children's Mental Health Alliance Foundation, and Allan N. Schore, Ph.D.
Schore, assistant clinical professor in the department of psychiatry and biobehavioral sciences at UCLA School of Medicine, has been compared to Einstein in his quest for a field theory, an overarching model that would explain all aspects of neuropsychobiological function and dysfunction.
In their presentation and subsequent interviews with Psychiatric Times, Schore and Siegel integrated the latest findings from neuroscience, development, attachment and psychoanalysis--fields that for too long have failed to merge their impressions into a coherent whole. As Schore explained, "The attachment researchers have studied the experiences necessary for social and emotional development, but they have looked only at behaviors and not at brain structures. The brain development people have looked at structures and not at behavioral consequences."
Attachment theory holds that secure attachments, and the attuned infant-caregiver interactions that produce them, are crucial to healthy psychological development. Schore takes attachment theory a step further by correlating the dialogue of caregiver-infant attunement with its accompanying neurobiological states, and explaining how these states may promote the wiring of healthy brain circuitry.
Infant researchers, among them psychiatrist Daniel Stern, M.D. (1977), have described this attunement dialogue. Researchers Beebe and Lachmann (1988) were the first to document its second-by-second nuances. Their photographed sequences reveal mother and infant face-to-face, their gazes interlocking, and their expressions modeling and mirroring one another. By tuning in to every subtle shift in the infant's states, the caregiver accentuates positive states of excitement, joy and pleasure, and minimizes distress. As Siegel describes it, "the infant feels felt." In this way, the mother serves as an affect regulator, an auxiliary cortex for the infant's still underdeveloped brain.
Siegel offered an example of an attuned interaction. "Imagine that an 11-month-old baby is excited about having just gotten up. She is cruising along the side of a table, her face filled with glee, and says "Aaaawwww!' The parent's attuned response would be "Wow!" reflecting the same crescendo and decrescendo, the same profile of energy."
Extrapolating from animal research, and from an ever-growing body of brain imaging studies on humans, Schore locates these attunement interactions in the infant's right orbitofrontal cortex and contends that they are essential to its synaptic development.
The orbitofrontal cortex sits at the apex of the limbic system, and controls the sympathetic and parasympathetic branches of the autonomic nervous system. Schore conceptualizes psychobiological attunement as "direct right brain to right brain communication" in which the mother's right brain, "involved in the unconscious expression and processing of emotional information," serves as a template for the infant's developing neural circuitry (Schore, 1997).
These attachment experiences occur at the same time that the neonatal brain is undergoing a growth spurt. Brain researchers Greenough and Black (1992) first described a model of the brain's "experience-dependent synaptogenesis" in which there is a surge of metabolic activity--an overpro-liferation of synapses. Regardless of genetic encoding, synapses that fail to form connections die off in a process of pruning. Schore contends that abuse, neglect and chronic states of misattunement lead to an overpruning of synapses in the right orbitofrontal cortex, leaving individuals with impaired ability to modulate and regulate emotion in response to stress.
By regulating affect, the caregiver is also regulating the release of neurohormones in the infant's brain. High levels of cortisol, a stress hormone that may well be released in the brain during states of distress, has been shown in some animal studies to destroy synapses.
In the inevitable event of distress states in the infant, the caregiver's moving in to repair the connection and comfort the infant reduces the levels of cortisol and related stress hormones. As a result, the frontal cortex develops a greater concentration of glucocorticoid receptors that can modulate stress responses (Schore, 1996).
When there is no interactive repair; when the caregiver is abusive, neglectful or continually misattuned, infants may remain in chronically negative states, their corticosteroid levels chronically elevated. This results in a reduction in the number of synapses, even the death of neurons, according to Schore's hypothesis.
Attachment researchers have recently begun to document the endocrinological correlates to insecure attachment (Main, 1996). In the classic strange-situation test developed by attachment researchers, a mother first takes the baby into a room where they encounter a stranger. The mother leaves the infant alone with the stranger briefly and then returns. The infant's response to these stressful separation and reunion events provides a measure of the security of attachment. Securely attached infants may be moderately upset at the disappearance of the mother, but welcome her return fairly unequivocally and are quickly soothed by her ministrations. These children exhibit a rise in cortisol at separation followed by a diminution at reunion.
In the most pathological attachment category, the insecure-disorganized attachment, infants react to the mother's return with disorganized, conflicted, sometimes self-harming behavior. Siegel described their behavior: "Children may go toward the parent, then go away, spin around, bang their heads on the wall, kick the floor." Instead of comfort, the return of the parent leads to a "state of disorganization in the child." Disorganized attachments appear to occur in the presence of abuse or frightening and disorienting parental behavior. Children with these disorganized attachments exhibit a greater rise in cortisol and prolonged cortisol elevations across the course of the strange-situation test. When children with disorganized attachments were followed for 17 years, they also showed the greatest vulnerability to mental disorders later in life.
Animal research, which allows for the direct examination of brain tissue following particular social experiences, has long suggested that social relationships alter the very structure of the brain. Monkeys raised in social isolation not only manifest symptoms of emotional dysregulation, but also a lack of fundamental neurons in portions of the hippocampal formation, a region of the brain involved in regulating emotion (Nelson and Bloom, 1997).
Carlson and Earls (1997) recently documented similar neuroendocrinological abnormalities in children institutionalized in Romanian orphanages. Whether these abnormalities can be reversed with improved social relationships remains to be seen.
In the last few years, the burgeoning of position emission tomography (PET) scanning, regional magnetic resonance imaging (MRI) and other less-invasive brain imaging technologies have begun to provide more direct evidence of the interaction between early experience and brain structure in humans.
A recent PET study of regional cerebral blood flow by Chiron et al. (1997) confirmed that the right brain is predominant in infancy through the third year of life, suggesting that its major development occurs during the period when attachments are forged. Jones et al. (1997) have recently found differences in the pattern of electro encephalogram (EEG) activation in the infants of depressed versus nondepressed mothers. At 3 months of age, 12 out of 17 infants of depressed mothers showed greater relative right frontal EEG asymmetry, compared to only two out of 15 infants of nondepressed mothers (Field et al., 1995).
This pattern mirrored the depressed mothers' EEG abnormalities, with 10 out of 17 (versus three out of 15 in the nondepressed group) depressed mothers showing relative right frontal EEG asymmetries. No discernible differences in affect between the two study groups accounted for these differences. While these EEG abnormalities may simply reflect inborn genetic differences, they are also suggestive of the notion of mother's right brain to infant's right brain modeling. As Siegel explained, "The repeated experience of certain states can result in their becoming traits." This finding of greater relative right frontal EEG asymmetry has now been borne out in infants as young as 1 month of age (Jones and Field, 1997).
Several other studies have established that infants mirror the depressive symptoms of their mothers as early as 3 months by exhibiting fewer positive facial expressions, more negative ones and lower activity levels. Dawson et al. (1997) found that 11- to 17-month-old infants of depressed mothers exhibited increased EEG activation in the frontal region when expressing negative emotions. Even when expressing seemingly identical emotional states, the infants of nondepressed mothers had less EEG activity in the frontal regions.
In a study of adolescents, Teicher et al. (1997) recently found abnormal EEG readings in the frontotemporal or anterior regions in 42.9% of those with a history of psychological abuse, 54.4% of those with physical/sexual abuse, and 71.9% of the subsample with serious physical/sexual abuse, as compared to 26.9% of patients with no abuse. Early abuse was associated with left hemisphere abnormalities and a reversed left/right hemisphere asymmetry, causing Teicher to hypothesize that early abuse exerted a deleterious effect on left cortical and hippocampal development, and impeded hemispheric integration and the establishment of left cortical dominance.
If attachment experiences shape the circuitry of the brain and faulty circuitry leaves individuals vulnerable to later emotional dysregulation, what evidence is there for neuronal plasticity once the critical period has passed? And if plasticity remains, which psychotherapeutic interventions stand the best odds of growing new synapses?
As both psychotherapists and integrative thinkers, Siegel and Schore have come to some tentative assumptions. In general, the research suggests that "talking therapy" must do more than talk if the problem is in areas of the right brain unresponsive to verbal interventions. Schore believes that particularly when there is a therapeutic rupture, a misattunement with the therapist, the patient may move into a highly emotional state where the right brain becomes dominant. "What will get through is tone of voice, demeanor, facial expressions and a sense of empathy that is rooted in the early psychobiological attunement between mother and infant," says Schore.
For Siegel, aligning with the patient's state--direct right-brain to right-brain communication--and then expressing that affective state in fairly straightforward terms can be helpful to many patients. "I find myself saying things that I would never consciously think of saying like Oh, that was too much.' These sorts of clarifying and attuned statements of feeling emerge unconsciously and can be the most helpful." Of course, right-brain to right-brain communication alone does not constitute psychotherapy. For Siegel, coconstructing a more linear narrative that integrates left- and right-brain functions is also essential.
But numerous psychotherapy outcome studies have shown that when patients recount what was most helpful about psychotherapy, they don't often recall specific interpretations or insights. What they remember is the quality of the relationship, the way it felt to be in the room with the therapist or to share a mutual gaze--experiences reminiscent of early attunement. Whether such experiences actually promote new neural connections in the patient's right hemisphere and better coordination between right and left hemispheres is an open question.
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